This year we will be discussing important factors in tobacco control including; youth smoking, the role of the tobacco industry, use of mass media for smoking prevention and cessation, smokefree legislation, harm reduction and the neurobiology of nicotine addiction.

In addition to the topics covered on our previous tobacco control CPD, we will also be examining in detail the current evidence on tobacco harm reduction, electronic cigarettes and other nicotine-containing devices.

More information about these courses can be found on our website @ UKCTAS.net

The study identifies “denying, distortion and distraction” as main strategies!

The alcohol industry (AI) is misrepresenting evidence about the alcohol-related risk of cancer with activities that have parallels with those of the tobacco industry, according to new research published in the journal Drug and Alcohol Review.

Led by the London School of Hygiene & Tropical Medicine with the Karolinska Institutet, Sweden, the team analysed the information relating to cancer which appears on the websites and documents of nearly 30 alcohol industry organisations around the world between September 2016 and December 2016. Most of the organisational websites (24/26) showed some sort of distortion or misrepresentation of the evidence about alcohol-related cancer risk, with breast and colorectal cancers being the most common focus of misrepresentation.

The most common approach involves presenting the relationship between alcohol and cancer as highly complex, with the implication or statement that there is no evidence of a consistent or independent link. Others include denying that any relationship exists or claiming inaccurately that there is no risk for light or ‘moderate’ drinking, as well discussing a wide range of real and potential risk factors, thus presenting alcohol as just one risk among many.

According to the study, the researchers say policymakers and public health bodies should reconsider their relationships to these alcohol industry bodies, as the industry is involved in developing alcohol policy in many countries, and disseminates health information to the public.

Alcohol consumption is a well-established risk factor for a range of cancers, including oral cavity, liver, breast and colorectal cancers, and accounts for about 4% of new cancer cases annually in the UK1. There is limited evidence that alcohol consumption protects against some cancers, such as renal and ovary cancers, but in 2016 the UK’s Committee on Carcinogenicity concluded that the evidence is inconsistent, and the increased risk of other cancers as a result of drinking alcohol far outweighs any possible decreased risk².

This new study analysed the information which is disseminated by 27 AI-funded organisations, most commonly ‘social aspects and public relations organisations’ (SAPROs), and similar bodies. The researchers aimed to determine the extent to which the alcohol industry fully and accurately communicates the scientific evidence on alcohol and cancer to consumers. They analysed information on cancer and alcohol consumption disseminated by alcohol industry bodies and related organisations from English speaking countries, or where the information was available in English.

Through qualitative analysis of this information they identified three main industry strategies. Denying, or disputing any link with cancer, or selective omission of the relationship, Distortion: mentioning some risk of cancer, but misrepresenting or obfuscating the nature or size of that risk and Distraction: focusing discussion away from the independent effects of alcohol on common cancers.

Mark Petticrew, Professor of Public Health at the London School of Hygiene & Tropical Medicine and lead author of the study, said: “The weight of scientific evidence is clear – drinking alcohol increases the risk of some of the most common forms of cancer, including several common cancers. Public awareness of this risk is low, and it has been argued that greater public awareness, particularly of the risk of breast cancer, poses a significant threat to the alcohol industry. Our analysis suggests that the major global alcohol producers may attempt to mitigate this by disseminating misleading information about cancer through their ‘responsible drinking’ bodies.”

A common strategy was ‘selective omission’ – avoiding mention of cancer while discussing other health risks or appearing to selectively omit specific cancers. The researchers say that one of the most important findings is that AI materials appear to specifically omit or misrepresent the evidence on breast and colorectal cancer. One possible reason is that these are among the most common cancers, and therefore may be more well-known than oral and oesophageal cancers.

When breast cancer is mentioned the researchers found that 21 of the organisations present no, or misleading, information on breast cancer, such as presenting many alternative possible risk factors for breast cancer, without acknowledging the independent risk of alcohol consumption.

Professor Petticrew said: “Existing evidence of strategies employed by the alcohol industry suggests that this may not be a matter of simple error. This has obvious parallels with the global tobacco industry’s decades-long campaign to mislead the public about the risk of cancer, which also used front organisations and corporate social activities.”

The researchers say the results are important because the alcohol industry is involved in conveying health information to people around the world. The findings also suggest that major international alcohol companies may be misleading their shareholders about the risks of their products, potentially leaving the industry open to litigation in some countries.

Professor Petticrew said: “Some public health bodies liaise with the industry organisations that we analysed. Despite their undoubtedly good intentions, it is unethical for them to lend their expertise and legitimacy to industry campaigns which mislead the public about alcohol-related harms. Our findings are also a clear reminder of the risks of giving the AI the responsibility of informing the public about alcohol and health.

“It has often been assumed that, by and large, the AI, unlike the tobacco industry, has tended not to deny the harms of alcohol. However, through its provision of misleading information it can maintain what has been called ‘the illusion of righteousness’ in the eyes of policymakers, while negating any significant impact on alcohol consumption and profits.

“It’s important to highlight that if people drink within the recommended guidelines they shouldn’t be too concerned when it comes to cancer. For accurate and accessible information on the risks, the public can visit the NHS website.”

The authors acknowledge limitations of their study including that there are many other mechanisms and organisations through which industry disseminates health-related information which they did not examine, although it is unlikely that the messages would be different.

The researchers also say there is an urgent need to examine other industry websites, documents, social media and other materials in order to assess the nature and extent of the distortion of evidence, and whether it extends to other health information, for example, in relation to cardiovascular disease.

2Committee on Carcinogenicity of chemicals in food, consumer products and the environment (COC). Statement 2015/S2.

About the London School of Hygiene & Tropical Medicine:

The London School of Hygiene & Tropical Medicine is a world-leading centre for research and postgraduate education in public and global health, with more than 4,000 students and 1,000 staff working in over 100 countries. The School is one of the highest-rated research institutions in the UK, is among the world’s leading schools in public and global health, and was named University of the Year in the Times Higher Education Awards 2016. Our mission is to improve health and health equity in the UK and worldwide; working in partnership to achieve excellence in public and global health research, education and translation of knowledge into policy and practice. http://www.lshtm.ac.uk

Alcohol consumption will cause 63,000 deaths in England over the next five years according to a new report from the University of Sheffield Alcohol Research Group.

The report, published by the Foundation for Liver Research, predicts that 32,475 of the deaths – the equivalent of 35 a day – will be the result of liver cancer and another 22,519 from alcoholic liver disease.

In its new report, Financial case for action on liver disease, endorsed by the independent Lancet Commission on Liver Disease, the Foundation for Liver Research urges the Government to implement a suite of policy measures designed to mitigate the rising health and financial burden of alcohol, including the introduction of minimum unit pricing (MUP), re-institution of alcohol duty escalator and advertising restrictions.

Between 2017 and 2022 the total cost to the NHS of alcohol-related illness and deaths will be £17 billion.

Providing evidence in support of Government intervention, new modelling shows that within five years of its introduction in England, a 50p MUP alone would result in:

1,150 fewer alcohol-related deaths

74,500 fewer alcohol-related hospital admissions

Savings of £325.7m in healthcare costs

Savings of £710.9m in crime costs

The total financial savings to the public purse of MUP is forecast to be £1.1 billion – the equivalent cost of the Government’s recently announced investment package for Northern Ireland.

Colin Angus, Research Fellow at the University of Sheffield and part of the Sheffield Alcohol Research Group who conducted the research, said:

“These new findings show there will be 35 deaths and 2,300 hospital admissions due to alcohol every day in England over the next five years. We estimate this will cost the NHS £17 billion at a time when healthcare resources are already overstretched. Our research also shows that policies such as Minimum Unit Pricing have the potential to significantly reduce this burden.”

Liver disease is one of Britain’s biggest killers, claiming about 12,000 lives a year in England alone. The number of deaths associated with it has risen by 400% since 1970. It is estimated that 62,000 years of working life are lost every year as a result of it. People who develop serious liver problems also suffer some of the worst health outcomes in western Europe.

The report from the World Cancer Research Fund outlined the latest evidence on how we can reduce that risk – focusing on weight, physical activity and drinking.

The WCRF studies all the evidence on a potential risk and decides whether it’s strong enough to be a basis for making recommendations to the public.

Breast cancer is the most common cancer in the UK, and 1 in 8 women will be diagnosed with breast cancer at some point in their lives. And since we know that almost a third of breast cancer cases in the UK could be prevented, largely by changes to lifestyle, this is important stuff.

While the cause of an individual’s cancer can never be certain, there are still things you can do to reduce your risk. And evidence like this is the first step to helping women to do just that.

So what exactly does the report say?

Alcohol

The report backs up previous research showing that drinking alcohol can cause 7 types of cancer including breast cancer. Even though it’s in the headlines, this is nothing new.

While the reports may sound alarming, we also know that the more you cut down, the more you’re reducing your risk.

Although most women don’t regularly drink very large amounts of alcohol, thousands of cases of cancer – including breast – are linked to alcohol each year.

There are 3 good theories on the link between alcohol and cancer which we’ve written about before.

When we drink alcohol, it’s broken down into a toxic chemical called acetaldehyde. Acetaldehyde can damage the DNA inside our cells, and then prevent damage from being repaired. This is important because it allows cancer to develop.

Alcohol can increase the levels of certain hormones in the body, including oestrogen. We know that high levels of oestrogen can fuel the development of breast cancer, so this might be particularly important here.

Alcohol also makes it easier for cells in the mouth and throat to absorb other cancer-causing chemicals. This is probably more important for other cancer types linked to alcohol rather than breast cancer.

Physical activity

The evidence on the link between breast cancer risk and both weight and physical activity is a bit more complicated. This is because there is evidence that the causes of breast cancer that occur in women before the menopause, compared to after the menopause, are different.

But overall there is strong evidence that keeping a healthy weight and being physically active, can help prevent breast cancer.

Unlike its previous report, this time WCRF says that some forms of physical activity probably reduce the risk for pre-menopausal breast cancer But the finding is only true for ‘vigorous’ activity – exercise which gets you breathing hard and your heart beating fast, so that you won’t be able to say more than a few words without pausing for breath.

The report also adds to the existing evidence that physical activity at any age is related to a lower risk of breast cancer in women after the menopause. This can be anything that gets you a bit hot and out of breath – from fast walking, to cycling, or even heavy housework. And the more you do the better.

Body weight

The evidence on weight and breast cancer is also complicated: as your risk changes depending on the ages at which you were overweight.

But overall the report agrees with previous work showing that being overweight or obese throughout adulthood causes postmenopausal breast cancer, something that is already well established.

Bringing it all together

Other things that affect a woman’s breast cancer risk are less easy to control. As with most cancers, the risk of developing the disease increases with age. Having a family history of the disease can increase a woman’s risk, and breastfeeding can reduce it.

All the different things that can increase the risk of breast cancer are held together by a common thread: they all affect the hormones circulating around in the body in some way.

Hormones help control what happens inside our bodies by sending messages from one place to another – including instructing cells when to stop and start multiplying.

If this system goes wrong, cells can get too many messages telling them to make more cells. And that can lead to cancer.

Overall the best advice is the same as at the start of the week: to keep active, keep a healthy weight throughout life, and limit alcohol.

The Institute of Alcohol Studies (IAS) and the Scottish Health Action on Alcohol Problems (SHAAP) are co-hosting a four part seminar series to discuss issues relating to women and alcohol.

Each session will be chaired by an eminent academic, who will invite three guest speakers to present their personal responses to three pre-set questions, which are relevant to the topic.

These events will provide an opportunity for policy makers, academics, activists, and media representatives to critically discuss topics related to women and alcohol use. The intention is to stimulate thinking, challenge some attitudes and perceptions, and to think about future research and policy priorities.

Seminar 1: Friday, 10th March 2017

Women, Alcohol, and Globalisation.
Royal College of Physicians, London, 2 – 4pm

Chair: Dr. Cecile Knai, Associate Professor of Public Health Policy, London School of Hygiene and Tropical Medicine.

How does alcohol marketing influence women’s behaviours?

How does alcohol marketing influence attitudes towards women?

How does alcohol affect women in different social and cultural contexts?

Connor [1] argues there is strong epidemiological evidence that alcohol causes cancer but highlights uncertainty about how this message may be understood by the ‘wider public’. We agree that there is public confusion and scepticism about public health advice on drinking, and that alcohol industry actors will seek to exploit this by ‘framing’ the debate in ways which further their commercial interests [2, 3]. However, there is also a pressing need to take into account the wider social context in which any new scientific evidence is introduced [4].

People have multi-factorial understandings of the causes of chronic disease which encompass family history, environmental factors, stress and luck, as well as behavioural factors such as smoking and drinking; these factors are perceived as interconnecting, rather than independent, and may become more or less salient at particular points in the life-course [5, 6]. Davison and colleagues [7, 8] argue that, in an iterative process similar to formal epidemiology, ‘lay’ epidemiologists extract information from mainstream health messages and observe patterns of illness and death among family, friends, acquaintances and those in public life to generate and reformulate hypotheses about ‘candidates’ for particular health problems. Gender, age and socio-economic status are also relevant here [9, 10]. Crucially, uncertainty is a key feature of lay epidemiology; some ‘candidates’ are observed to ‘do all the wrong things’ but live long lives (‘unwarranted survivals’: ‘the fat “Uncle Norman” figure who has survived into a healthy old age, despite extremely heavy smoking and drinking’) ([5], p. 682), while other people lead apparently ‘healthy’ lives but still suffer premature illness or death (‘anomalous deaths’). The ‘anomalous death’ of a relative is particularly important in undermining epidemiological evidence about risk factors for major diseases [11].

There are a number of reasons why the message ‘alcohol causes cancer’ may not fit easily with lay epidemiology. First, candidacy only indicates increased risk—not an inevitable outcome–so a message which emphasizes certainty rather than probability may be disregarded. Research investigating the acceptability of cancer warning messages among Australian drinkers [12] suggests that statements about alcohol leading to an ‘increased risk of cancer’ performed better than those which stated that alcohol ‘can cause cancer’.

Secondly, lay epidemiology encompasses an understanding of the different meaning of risk factors at the population and individual level: ‘most people have notions about what renders a person “a candidate” for a specific disease [incorporating “expert” epidemiological understandings of risk at the population level] whilst simultaneously understanding that life, health and death defy prediction at an individual level’ ([11], p. 445). Thus, simple health messages which focus exclusively upon behavioural risk factors at an individual level draw attention to ‘unwarranted survivals’ and particularly to ‘anomalous deaths’ in people’s social networks. The observation that behavioural change does not guarantee a reduction of risk at an individual level (mirroring epidemiological concerns about the ‘prevention paradox’) [11, 13] may therefore result in public scepticism.

Thirdly, while smokers are currently viewed as ‘candidates’ for cancer, it appears that drinkers are not; lay people struggle to find an explanation for non-smokers who develop cancer and instead emphasize the unpredictability and randomness of the disease [14]. Finally, it is important to explore how terms such ‘drinkers’ and ‘drinking’ might be interpreted by the wider public. While ‘smoking causes cancer’ draws on the commonly understood binary opposition between smokers and non-smokers, ‘drinking causes cancer’ may well be understood as comparing ‘heavy’ drinkers with ‘light’ or ‘moderate’ drinkers, rather than contrasting drinkers with non-drinkers. Qualitative research in the United Kingdom demonstrates that drinking is perceived as a routine activity associated with sociability, pleasure and relaxation and that heavy weekend drinking and drinking to intoxication are normalized; thus, drinking alone or choosing not to drink alcohol are behaviours which require explanation, not excessive drinking in general [13, 15-17]. In addition, people construct themselves as responsible, moderate drinkers and position other groups as the ‘problematic’ drinkers. For example, respondents in mid-life portray themselves as ‘experienced’ drinkers and younger people as irresponsible ‘problem’ drinkers [15], younger adults position older people, especially older women drinking heavily in public, as problematic [18], while younger middle-class women position working class women as vulgar and excessive drinkers [19]. This suggests that ‘drinking causes cancer’ may be interpreted as ‘other people’s excessive drinking causes cancer’.

Connor demonstrates the strength of the evidence for alcohol consumption as a cause of cancer. Further research on how lay people conceptualize drinkers and drinking when assessing candidacy is necessary before this message can be communicated effectively to the public.

Declaration of interests

C.E. is a member of the Alcohol Research UK Grants Advisory Panel and has received research funding from Scottish Health Action on Alcohol Problems. S.M. has no competing interests to declare.

Acknowledgements

Thanks to Kate Hunt, Charlie Davison, Una Macleod and Graham Watt for previous conversations about lay epidemiology, and to Penny Buykx for useful suggestions for literature for this commentary.